(NR 508 Week 6 Grand Rounds Assignment Using Kaltura)
Daniel is a 45 year old male who presents with complaints of shortness of breath, and chest tightness. Audible wheezing is heard and he states he has had a slight cough. He has been a non-smoker for 2 years. He is able to speak in complete sentences, but states he becomes easily out of breath after climbing a few stairs at home. … states he has been coughing frequently which has … him from adequately getting enough sleep at night.
History of Present Illness: Daniel denies any a history of asthma, COPD, or lung disease. He states he becomes winded and SOB with minimal exercise. On exam he is sitting upright with excessive accessory muscle use. While auscultating his lungs he has expiratory wheezing bilaterally.
Primary Medical History: Daniel denes any other medical problems. He has NKDA and does not take any medications on a daily basis. He has no other pertinent medical or surgical history. Patient is a non-smoker, does not use alcohol/drugs, and drinks about 3 cups of coffee a day.
Vital Signs: Blood Pressure 145/86, Temperature 99.3, Pulse 105, Respirations 24/min, Oxygen Saturation: 92% on room air. He is 5 ft 11inches and 175 lbs.
EKG: Sinus Tachycardia, WNL